Twenty years of childhood coeliac disease in The Netherlands: a rapidly increasing incidence?

Clinical characteristics of hospitalized term and preterm infants with community-acquired viral pneumonia

BACKGROUND

Pneumonia is a serious problem that threatens the health of newborns. This study aimed to investigate the clinical characteristics of hospitalized term and preterm infants with community-acquired viral pneumonia.

METHODS

This was a retrospective analysis of cases of community-acquired viral pneumonia in the Neonatal Department. Nasopharyngeal aspirate (NPA) samples were collected for pathogen detection, and clinical data were collected. We analysed pathogenic species and clinical characteristics among these infants.

RESULTS

RSV is the main virus in term infants, and parainfluenza virus (PIV) 3 is the main virus in preterm infants. Patients infected with PIV3 were more susceptible to coinfection with bacteria than those with respiratory syncytial virus (RSV) infection (p < 0.05). Preterm infants infected with PIV3 were more likely to be coinfected with bacteria than term infants (p < 0.05), mainly gram-negative bacteria (especially Klebsiella pneumonia). Term infants with bacterial infection were more prone to fever, cyanosis, moist rales, three concave signs, elevated C-reactive protein (CRP) levels, respiratory failure and the need for higher level of oxygen support and mechanical ventilation than those with simple viral infection (p < 0.05). The incidence of hyponatremia in neonatal community-acquired pneumonia (CAP) was high.

CONCLUSIONS

RSV and PIV3 were the leading causes of neonatal viral CAP. PIV3 infection is the main cause of viral CAP in preterm infants, and these individuals are more likely to be coinfected with bacteria than term infants, mainly gram-negative bacteria. Term infants with CAP coinfected with bacteria were more likely to have greater disease severity than those with single viral infections.

Exposure to antibiotics during pregnancy alters offspring outcomes

INTRODUCTION

The composition of microorganisms is closely related to human health. Antibiotic use during pregnancy may have adverse effects on the neonatal gut microbiome and subsequently affect infant health development, leading to childhood atopy and allergic diseases, intestinal, metabolic and brain disorders, and infection.

AREAS COVERED

This review includes the effect of maternal antibiotic use during pregnancy on potential diseases in animals and human offspring.

EXPERT OPINION

Exposure to antibiotics during pregnancy alters offspring outcomes. Alterations in the microbiome may potentially lower the risk of a range of problems and may also be a novel therapeutic target in children later in life.

Systematic review and meta-analysis: the incidence and prevalence of paediatric coeliac disease across Europe

BACKGROUND

Coeliac disease is one of the most prevalent immune-mediated gastrointestinal disorders in children.

AIM

To review the incidence and prevalence of paediatric coeliac disease, and their trends, regionally across Europe, overall and according to age at diagnosis.

METHODS

Systematic review and meta-analysis from January 1, 1950 to December 31, 2019, based on PubMed, CINAHL and the Cochrane Library, searches of grey literature and websites and hand searching of reference lists. A total of 127 eligible studies were included.

RESULTS

The prevalence of previously undiagnosed coeliac disease from screening surveys (histology based) ranged from 0.10% to 3.03% (median = 0.70%), with a significantly increasing annual trend (P = 0.029). Prevalence since 2000 was significantly higher in northern Europe (1.60%) than in eastern (0.98%), southern (0.69%) and western (0.60%) Europe. Large increases in the incidence of diagnosed coeliac disease across Europe have reached 50 per 100 000 person-years in Scandinavia, Finland and Spain. The median age at diagnosis increased from 1.9 years before 1990 to 7.6 since 2000. Larger increases in incidence were found in older age groups than in infants and ages <5 years.

CONCLUSIONS

Paediatric coeliac disease incidence and prevalence have risen across Europe and appear highest in Scandinavia, Finland and Spain. The most recent evidence shows large increases in incidence in most regions, but stabilisation in some (notably Sweden and Finland). Sharp increases in the age at diagnosis may reflect increases in milder and asymptomatic cases diagnosed since reliable serology testing became widely used, through endomysial antibodies after 1990 and tissue transglutaminase antibodies around 2000.

A prospective study of catch-up growth among Indian children with celiac disease

OBJECTIVES

The study was done to investigate the response of the gluten-free diet (GFD) on growth and other biochemical parameters in newly diagnosed children with celiac disease (CD). We also determined the association of Marsh biopsy classification and the response in haematological parameters among the children with GFD over the follow-up time.

METHODS

A prospective observational study was conducted for 1.5 years where children aged 1-10 years with newly confirmed CD (as per Marsh classification) without pre-existing chronic disease were enrolled. Individual anthropometry, biochemical and haematological parameters were recorded on enrolment and compared with 1, 3 and 6 months (follow-up) after initiating GFD (as per World Health Organization growth charts).

STATISTICAL ANALYSIS

The data were entered in MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences version 21.0. A P value of < 0.05 was considered significant.

RESULTS

A total of 51 (out of 55) children with CD completed 6-month follow-up. A significant improvement in the growth and biochemical parameters was seen at 6-month follow-up with the GFD (P < 0.05). There was a significantly decreasing Hb (at enrolment and at 3 months) with increasing Marsh biopsy grade-it was significantly less with Marsh 3C and more with Marsh 3A. A significantly better %Hb improvement was seen in children with Marsh biopsy 3C as compared to 3A and 3B (P < 0.05). We found no significant association of Marsh biopsy with Malabsorption, type of anaemia and Serum ferritin levels (P > 0.05).

CONCLUSIONS

GFD showed significant improvement in the growth and development of the child with a significant reduction in anaemia at 6 months. With increasing grade of Marsh biopsy, the severity of anaemia increases but after the initiation of GFD, such children show significantly better improvement in %Hb over time.

Changing Pattern of Childhood Celiac Disease Epidemiology: Contributing Factors

Up until the 1960s and 1970s, diarrhea, malabsorption syndrome, and failure to thrive were the presenting symptoms and signs of celiac disease (CD) in young infants; however this disease was also at the same time reported to be disappearing. Indeed, clinical childhood CD was seen to transform into a milder form, resulting in an upward shift in age at diagnosis during the 1970s (and years later for many countries). This changing pattern of CD presentation then altered the epidemiology of the disease, with major differences between and within countries observed. An awareness of the changing clinical nature of CD and use of case-finding tools to detect even clinically silent CD became an important factor in this changing epidemiology. Countries report both low and high prevalence but it seems to be on the increase resulting in a population-based level of 1-2%. This paper discusses the potential causes and environmental factors behind these observed clinical changes, identifying new clues from different studies published at the time this transformation took place. For instance, it was found that breastfeeding postponed the diagnosis of the disease but did not altogether prevent it. Moreover, gluten introduction at a young age, specifically at the mean age of 2 months, seemed to also have a clear impact in inducing malabsorption syndrome and failure to thrive in young infants in addition to other factors such as gluten intake volume and type of cereal present in the weaning food. Further, the impact of cow's milk and its high osmolarity might have played an important role; humanized milk formulas were not yet invented. Future epidemiological studies on the contributing environmental factors to the shift in CD presentation are thus recommended for countries in which these changing clinical features are still being observed.

Celiac Disease: Clinical Features and Diagnosis

The presentation in celiac disease is shifting from the classical malabsorptive presentation to more nonclassical presentations, requiring clinicians to maintain a high level of suspicion for the disease and to be aware of the possible extraintestinal manifestations. The diagnosis of celiac disease is guided by initial screening with serology, followed by confirmation with an upper endoscopy and small intestinal biopsy. In some pediatric cases, biopsy may be avoided.

The clinical presentation of coeliac disease in 1030 Swedish children: Changing features over the past four decades

BACKGROUND

The features of paediatric coeliac disease have changed in recent decades. We hypothesised that the age at diagnosis might continue to increase, whereas the severity of symptoms should decrease.

METHODS

In the present study, filed data on 1030 paediatric patients diagnosed with coeliac disease between 1973 and 2013 were analysed. The information available covered 99.8% of small bowel biopsies and included information on sex, age and clinical symptoms.

RESULTS

The age at diagnosis increased significantly, from a mean of 2.2 years during the first 10 years to 8.2 years in recent years. The proportion of children with severe symptoms declined from 92.8% to 78%, as did the proportion of biopsies characterised by severe pathology. In recent years, the monosymptomatic form of coeliac disease has been more common, and the number of patients detected at screening has increased. The frequency of patients with gastrointestinal symptoms, extra-intestinal symptoms, and failure to thrive and/or short stature at presentation decreased.

CONCLUSIONS

The mean age of newly diagnosed patients has increased over the last 15 years. Currently, coeliac disease shows a less severe picture in terms of symptoms and intestinal pathology. Younger children suffer primarily from gastrointestinal symptoms and growth failure, and adolescents from extra-intestinal manifestations.

Coeliac disease is more common in children with high socio-economic status

AIM

There are a number of genetic and environmental factors that are associated with an increased risk of developing coeliac disease. Our aim was to determine whether socio-economic deprivation increases or reduces the development of the disease.

METHODS

A cross-sectional study identified all children <16 years old diagnosed with coeliac disease in the same tertiary paediatric centre between January 1995 and December 2011. Data, including age at diagnosis and postcode, were collected and linked with the quintile rank of the Welsh Index of Multiple Deprivation score 2008, a measure of socio-economic status.

RESULTS

We included 232 patients and identified a graded association between the prevalence of coeliac disease and socio-economic deprivation, which showed a higher rate in children living in more affluent areas. The largest difference was between the lowest deprivation level (rate/1000 = 1.16) and the highest deprivation level (rate/1000 = 0.49).

CONCLUSION

In our population, coeliac disease was more common in children in the higher socio-economic groupings. The reasons for this are not clear, but perhaps both the 'hygiene hypothesis' and the health seeking behaviours of parents with high socio-economic status are possible factors in the more frequent diagnosis of coeliac disease in this group.

Clinical practice : coeliac disease

Coeliac disease (CD) is an immune-mediated systemic condition elicited by gluten and related prolamines in genetically predisposed individuals and characterised by gluten-induced symptoms and signs, specific antibodies, a specific human leukocyte antigen (HLA) type and enteropathy. The risk of coeliac disease is increased in first-degree relatives, certain syndromes including Down syndrome and autoimmune disorders. It is thought to occur in 1 in 100-200 individuals, but still only one in four cases is diagnosed. Small-bowel biopsy is no longer deemed necessary in a subgroup of patients, i.e. when all of the following are present: typical symptoms or signs, high titres of and transglutaminase antibodies, endomysial antibodies, and HLA-type DQ2 or DQ8. In all other cases, small-bowel biopsy remains mandatory for a correct diagnosis. Therapy consists of a strictly gluten-free diet. This should result in complete disappearance of symptoms and of serological markers. Adequate follow-up is considered essential.

CONCLUSION

Although small-bowel biopsy may be omitted in a minority of patients, small-bowel biopsy is essential for a correct diagnosis of CD in all other cases. Diagnostic work-up should be completed before treatment with gluten-free diet instituted.

Clinical presentation of celiac disease among pediatric compared to adolescent and adult patients

BACKGROUND

Celiac disease (CD) is being increasingly recognized in adults though a majority of patients continue to be diagnosed in childhood.

AIM

To compare the clinical presentation and profile of newly diagnosed pediatric and adolescent/adult CD patients.

MATERIALS AND METHODS

Retrospective analysis of patients diagnosed with CD between year 1997 and 2007 in the pediatric group, and between year 2000 and 2007 in the adolescent/adult group was done for clinical presentation, endoscopic findings and duodenal histology.

RESULTS

A total of 434 children and 298 adults were studied. The mean age of diagnosis was 6.5 ± 2.5 years (1-11 years) in children and 29.3 ± 13.3 years (6-73 years) in adolescent/adults. The mean duration of symptoms before diagnosis was 3.5 ± 2.5 years in children and 4.9 ± 4.6 years in the latter. Diarrhea as the presenting symptom was seen in 74 % of children and 58.7 % of adolescent/adults. Anemia (on investigations) was seen in 84 % of children and 94 % of adolescent/adults.

CONCLUSIONS

Pediatric patients of CD present more often with typical features than adults. Atypical presentations are more common in adults and the latent period for diagnosis is also longer in adolescent/adults. There is a need for increasing awareness about CD, both among pediatricians and physicians caring for adult patients.

Specific celiac disease antibodies in children on a gluten-free diet

OBJECTIVE

Celiac disease (CD) is characterized by histologic alterations in small bowel biopsies. Circulating specific CD antibodies at the time of diagnosis and their disappearance after a gluten-free diet support the diagnosis of CD. We aimed to determine the behavior of the CD antibodies immunoglobulin A anti-tissue transglutaminase (anti-TG2) and immunoglobulin A endomysium (EMA) in children with CD after starting a gluten-free diet.

METHODS

This was a retrospective multicenter study in the Netherlands between 2001 and 2009. Inclusion criteria were all newly diagnosed patients with CD younger than 19 years who had at least 1 anti-TG2 and/or EMA measurement before and after starting a gluten-free diet. Eight different anti-TG2 kits were used with substrates of guinea pig TG2 in 1 (Sigma) and 7 human-recombinant TG2: Varelisa and EliA Celikey Phadia-GmbH; Orgentec Diagnostica-GmbH; Diarect AG; Roboscreen GmbH; Aeskulisa Diagnostics; Binding Site Ltd. EMA was analyzed with indirect immunofluorescence tests. Statistical analyses were performed by using mixed-model repeated measurements and survival analysis.

RESULTS

There were 129 children with CD included (mean age: 5.6 years; SD ± 4.2). The mean concentration of anti-TG2 decreased significantly within 3 months after starting a gluten-free diet (P < .0001). The cumulative percentage of children who became negative for EMA after ½, 1, 1½, and 2 years was 31%, 60%, 74%, and 87%, respectively. For anti-TG2, a comparable trend was shown: 35%, 55%, 64%, and 78%, respectively.

CONCLUSIONS

Doctors taking care of children with CD should be aware that the mean concentration of anti-TG2 will show a 74% decrease (95% confidence interval: 69%-79%) after 3 months of gluten-free diet, and ∼80% of the children will be sero-negative for EMA and anti-TG2 after 2 years of the diet.

In search of tetraploid wheat accessions reduced in celiac disease-related gluten epitopes

Tetraploid wheat (durum wheat) is mainly used for the preparation of pasta. As a result of breeding, thousands of tetraploid wheat varieties exist, but also tetraploid landraces are still maintained and used for local food preparations. Gluten proteins present in wheat can induce celiac disease, a T-cell mediated auto-immune disorder, in genetically predisposed individuals after ingestion. Compared to hexaploid wheat, tetraploid wheat might be reduced in T-cell stimulatory epitopes that cause celiac disease because of the absence of the D-genome. We tested gluten protein extracts from 103 tetraploid wheat accessions (obtained from the Dutch CGN genebank and from the French INRA collection) including landraces, old, modern, and domesticated accessions of various tetraploid species and subspecies from many geographic origins. Those accessions were typed for their level of T-cell stimulatory epitopes by immunoblotting with monoclonal antibodies against the α-gliadin epitopes Glia-α9 and Glia-α20. In the first selection, we found 8 CGN and 6 INRA accessions with reduced epitope staining. Fourteen of the 57 CGN accessions turned out to be mixed with hexaploid wheat, and 5 out of the 8 selected CGN accessions were mixtures of two or more different gluten protein chemotypes. Based on single seed analysis, lines from two CGN accessions and one INRA accession were obtained with significantly reduced levels of Glia-α9 and Glia-α20 epitopes. These lines will be further tested for industrial quality and may contribute to the development of safer foods for celiac patients.

Long-term histological follow-up of people with coeliac disease in a UK teaching hospital

BACKGROUND

Coeliac disease is a relatively common condition which is usually managed by placing patients on a gluten free diet. Follow up biopsies to confirm histological recovery are controversial with a considerable variation in practice observed.

AIM

To determine the length of time to histopathological recovery in a group of coeliac disease patients and its associations with clinicopathological data.

DESIGN AND METHODS

All patients attending a specialist coeliac disease clinic prior to March 2009 were entered onto a database which recorded various clinicopathological data. The histopathology reports for all duodenal biopsies were reviewed and each biopsy was given a histopathological disease score based on a modified Marsh grade.

RESULTS

Two hundred and eighty-four patients underwent index and at least one subsequent biopsy. Two-hundred and twenty-seven (80%) showed histopathological improvement and 100 (35%) returned to normal (median recovery time 1.9 years, inter-quartile range 1.0-4.8 years). Patients with less severe disease at diagnosis were more likely to show a better response (r = 0.281, P < 0.0001). Older patients demonstrated a shorter time to histopathological recovery (r = -0.200, P = 0.001). Compliance with a gluten free diet was correlated with the best biopsy score (r = -0.134, P = 0.040) and degree of histological recovery (r = 0.161, P = 0.014).

CONCLUSION

Current guidelines for the timing of repeat biopsy after commencing a gluten free diet are unclear, although 4-6 months has been recommended. This study shows that time to histological recovery is longer than traditionally thought and may need to take into account the patient's age at diagnosis, the initial disease score and the level of compliance with a gluten free diet.

Phenotypic variance in childhood coeliac disease and the HLA-DQ/DR dose effect

OBJECTIVE

Coeliac disease (CD) is associated with HLA-DQ2 and DQ8. The clinical picture is variable and certain human leucocyte antigen (HLA) DQ/DR combinations have a higher relative risk (RR) for CD than others. Moreover, the HLA-DQ gene-dose effect has an impact on the strength of the gluten-specific T-cell response and thus may correlate with clinical presentation and severity of CD. The aim of this study was to determine the correlation between HLA-DQ/DR-based genotypes and the variation in phenotypes of the disease.

MATERIAL AND METHODS

A total of 113 non-related Caucasian children clinically diagnosed with CD during the period 1980-2003 with a known HLA type were included in the study. Patients were divided into four categories according to amount of disease expression predisposing to HLA-DQ2 or HLA-DQ8 molecules and the known RR of their HLA-DR/DQ type for CD: high (DR3DQ2 homozygous and DR3DQ2/DR7DQ2), substantial (DR3DQ2/DR5DQ7 and DR5DQ7/DR7DQ2), moderate (DR3DQ2-DR4DQ8 and DR3DQ2/DR*DQ*) and low (DR7DQ2/DR*DQ*, DR4DQ8- DR*DQ* and DR*DQ*- DR*DQ*). The clinical data and HLA genotypes of these patients were compared.

RESULTS

The 113 children were diagnosed with CD at a mean age of 4.6 years and boys were significantly older than girls when diagnosed (p=0.01). RR for having CD was highest for the high HLA-risk group (RR 8.1). With the exception of a greater frequency of abdominal distension and fewer non-gastrointestinal symptoms in the substantial HLA-risk group, there were no significant differences in clinical characteristics or degree of severity of the small-bowel histological findings between the children in the different HLA-risk groups.

CONCLUSION

No correlation was found between disease severity and a double HLA-DQ2 gene dose.

Screening rules for growth to detect celiac disease: a case-control simulation study

Background

It is generally assumed that most patients with celiac disease (CD) have a slowed growth in terms of length (or height) and weight. However, the effectiveness of slowed growth as a tool for identifying children with CD is unknown. Our aim is to study the diagnostic efficiency of several growth criteria used to detect CD children.

Methods

A case-control simulation study was carried out. Longitudinal length and weight measurements from birth to 2.5 years of age were used from three groups of CD patients (n = 134) (one group diagnosed by screening, two groups with clinical manifestations), and a reference group obtained from the Social Medical Survey of Children Attending Child Health Clinics (SMOCC) cohort (n = 2,151) in The Netherlands. The main outcome measures were sensitivity, specificity and positive predictive value (PPV) for each criterion.

Results

Body mass index (BMI) performed best for the groups with clinical manifestations. Thirty percent of the CD children with clinical manifestations and two percent of the reference children had a BMI Standard Deviation Score (SDS) less than -1.5 and a decrease in BMI SDS of at least -2.5 (PPV = 0.85%). The growth criteria did not discriminate between the screened CD group and the reference group.

Conclusion

For the CD children with clinical manifestations, the most sensitive growth parameter is a decrease in BMI SDS. BMI is a better predictor than weight, and much better than length or height. Toddlers with CD detected by screening grow normally at this stage of the disease.

The incidence of coeliac disease in adult first degree relatives

BACKGROUND AND AIMS

Although prevalence of coeliac disease among first degree relatives of coeliac patients is well-known, only four studies are available about its incidence. We investigated whether first degree relatives found to be negative at a first serological screening can subsequently develop coeliac disease.

PATIENTS AND METHODS

In the last 6 years, endomysial antibodies were tested in 158 adult first degree relatives referred to our coeliac out-patient clinic. After at least a year, negative subjects were offered a second testing. Sixty-three accepted.

RESULTS

130/158 first degree relatives tested negative initially. Although one of them had developed coeliac disease after the first testing, at the second testing none of the 63 endomysial antibody negative first degree relatives proved positive. Incidence of coeliac disease among first degree relatives was 1/64 in 51 months, 0.437% year (95%CI 0.05-2.62). An analysis of the sample size showed that 10,000 first degree relatives must be followed up to significantly reduce the CI.

CONCLUSIONS

Although we confirmed the high prevalence of coeliac disease among first degree relatives (28/158, 17.7%), we found that the low incidence suggests that further studies are required to understand whether endomysial antibody negative first degree relatives need to be followed up.

Effect of a gluten-free diet on growth and small-bowel histology in children with celiac disease in India

BACKGROUND AND AIM

Follow-up studies on growth and histological recovery of children with celiac disease (CD) while on a gluten-free diet (GFD) are lacking from Asia. We therefore assessed the effects of this diet.

METHODS

Forty-two children with CD were enrolled. Weight and height were expressed as weight for height (WfH) and height standard deviation scores (HSDS), respectively. Twenty-five children had repeated duodenal biopsies after 1-2 years and 14 had a third biopsy after 3-7 years of GFD. Compliance was checked by regular interview and IgA antiendomysial antibody estimation (EMA).

RESULTS

At diagnosis (n = 25), mean HSDS was -3.3 +/- 1.6 with 76% having a HSDS of <-2; 60% were undernourished (WfH mean 81.6 +/- 5.7). Over a mean follow up of 3.7 years, HSDS improved to -1.3 +/- 1.7 and 84% cases achieved normal nutrition. Mean height velocity was 13.9 cm during first year and 5.6 cm in subsequent years. Small-bowel biopsies at diagnosis showed subtotal villous atrophy (Marsh IIIb) in 18 (72%) and partial villous atrophy (Marsh IIIa) in seven (28%) patients. Repeat biopsy at 1-2 years showed shift from subtotal to partial villous atrophy in 94% (n = 17/18) and normalization in one patient. In patients with Marsh IIIa improvement of partial villous atrophy was observed in all. Immunoglobulin A endomysial antibody was negative in 81%. Repeat biopsies at 5 years of GFD showed improvement to Marsh I-II, but none normalized.

CONCLUSION

The majority of children with CD show normalization of nutrition and growth after GFD. Small-bowel histology improves markedly but does not normalize even after 5 years of GFD.

Clinical features of celiac disease in Indian children: are they different from the West?

OBJECTIVE

This study was designed to prospectively evaluate the clinical features of celiac disease (CD) in a large group of Indian children and to compare them with those from the West.

PATIENTS AND METHODS

Over a period of 5 years, a total of 549 children (< or = 14 years) with a clinical suspicion of CD were evaluated. Their detailed clinical features, investigations, and follow-up data were recorded. Complete hemogram, endoscopic duodenal biopsy, and celiac serology were done in all of the cases. Celiac disease was diagnosed on the basis of modified European Society of Paediatric Gastroenterology, Hepatology and Nutrition criteria.

RESULTS

Celiac disease was diagnosed in 300 children; 39 were excluded because of lack of follow-up or poor response to gluten-free diet. The remaining 210 had normal villous architecture and served as controls. The mean (+/- standard deviation) age of children with CD was 6.7 +/- 3 years, and the mean duration of symptoms was 3.5 +/- 2.5 years. The majority (84%) presented with diarrhea; other features were failure to thrive in 91%, anemia in 84%, wasting in 87%, and stunting in 60% of cases. Among the serological tests, the best results were obtained with tissue transglutaminase. On follow-up (19.4 +/- 15.5 months), symptoms subsided in all cases of CD with a significant weight and height gain.

CONCLUSIONS

Indian children with CD present late, with a significant delay in diagnosis. The majority presents with classic symptoms of diarrhea, failure to thrive, and anemia. There is a need for increasing awareness to pick up the atypical forms of the disease.

Nutritional management of the gluten-free diet in young people with celiac disease in The Netherlands

BACKGROUND

For young people with celiac disease, adherence to the gluten-free diet may be difficult to achieve and gluten restriction may lead to insufficient nutrient intake and unbalanced food intake resulting in overweight. In The Netherlands, no nutritional information is available. Therefore, we evaluated the nutritional management and nutritional state in young celiac patients.

METHODS

The Dutch Celiac Society invited all its members aged 12 to 25 years to complete a food record and a questionnaire. Nutrient intakes were compared with the recommendations and the intake in the general population. Total immunoglobin A, endomysial antibody, tissue transglutaminase and IgA gliadin were determined, and height and weight were assessed.

RESULTS

Strict dietary compliance was reported by 75%. The fiber and iron intakes were significantly lower, and the saturated fat intake significantly higher than recommended but comparable with the general population. Most of the patients (61%) found the diet easy to follow. Regular medical controls were reported by 86% but regular dietary controls by only 7% of the patients. Mean and SD scores for height and body mass index were -0.3 +/- 1.1 and -0.3 +/- 0.8, respectively.

CONCLUSIONS

The dietary compliance in this group is high, the nutritional state is adequate, but the nutrient intake is not. Better medical and dietary support is necessary to prevent long-term complications and to achieve an ongoing satisfying management in this group of young patients with a chronic disorder.

A national prospective study on childhood celiac disease in the Netherlands 1993-2000: an increasing recognition and a changing clinical picture

OBJECTIVES

To investigate prospectively whether the incidence of diagnosed celiac disease (CD) is increasing in the Netherlands and whether the clinical presentation is changing.

STUDY DESIGN

All newly diagnosed cases of CD throughout the Netherlands were registered prospectively from 1993 to 2000. The clinical picture was compared with that noted in our former study (1975-1990).

RESULTS

The overall incidence rate of CD was 0.81/1000 live births, with a linear increase from 1993 to 2000. There was a significant increase in the number of subjects with partial villous atrophy of the small bowel mucosa. The clinical presentation has changed significantly: abdominal distention, chronic diarrhea, and failure to thrive are less common, and more children presented with weight < P10, abdominal pain, and lassitude. The median age at diagnosis also increased.

CONCLUSION

The recognition of childhood CD in the Netherlands has increased significantly during the last few years, and the clinical picture has changed as well. Our data may indicate an increasing awareness of the Dutch doctors working in Child Public Health, general practitioners, and pediatricians to recognize more subtle expressions of the disease.

Age related clinical features of childhood coeliac disease in Australia

Background

To describe the presenting clinical features of coeliac disease in a single paediatric centre, and to determine if the presenting features vary with age.

Methods

A review was conducted of children who had been referred with clinical suspicion of coeliac disease to the paediatric gastroenterology department of a tertiary paediatric hospital in Sydney, Australia. Coeliac disease was defined using standard histological criteria. Medical records were reviewed retrospectively.

Results

Clinical data were available for 74 cases of proven coeliac disease. Only 9% of patients were less than 2 years of age at diagnosis. Pre-school children (age <5 years) presented with different symptoms to school children (age ≥ 5 years). The most common presenting features in younger children were diarrhoea, irritability and weight loss. However, in older children, abdominal pain was the most common presenting feature.

Conclusion

We found a significant difference in the clinical features of coeliac disease in pre-school compared to school age children.

Coeliac disease in The Netherlands

BACKGROUND

The prevalence of adult coeliac disease in The Netherlands was studied in the Dutch Coeliac Disease Society and in blood donors but not in the general population. We therefore studied the prevalence of recognized and unrecognized coeliac disease in a large cohort, representative of the adult Dutch general population. Blood samples were available for anonymous research, as well as data on dietary habits, self-reported physical characteristics, health problems, quality of life and socio-economic circumstances.

METHODS

Subjects included 50,760 individuals who had previously participated in two large population-based studies on health status in relation to lifestyle factors. Recognized coeliac disease was studied in all subjects by identification of self-reported adherence to a gluten-free diet and subsequent confirmation of the diagnosis of coeliac disease. Unrecognized coeliac disease was studied in a random sample of 1440 out of the 50,760 subjects through serologic screening and human lymphocyte antigen (HLA) typing.

RESULTS

The prevalence of recognized coeliac disease was 0.016% (95% confidence interval 0.008-0.031) and of unrecognized coeliac disease 0.35% (95% confidence interval 0.15-0.81). Menarcheal age was higher in women with recognized coeliac disease than in women without coeliac disease.

CONCLUSIONS

The prevalence of adult recognized coeliac disease in The Netherlands is one of the lowest in Europe, while the prevalence of unrecognized coeliac disease is comparable with that in other European countries. Adult coeliac disease is strongly under diagnosed in The Netherlands. The higher menarcheal age in women with recognized coeliac disease may be explained by diagnostic delay.

The incidence of pediatric inflammatory bowel disease in the Netherlands: 1999-2001

BACKGROUND

The incidence of inflammatory bowel disease (IBD) seems to be rising. Incidence studies could provide more insight into geographical differences and thereby lead to the identification of etiological factors. The aim of this study was to prospectively assess the incidence of pediatric IBD in the Netherlands from 1999 to 2001, using both an active physician case-reporting registry and a nationwide pathology database.

METHODS

All pediatricians in the Netherlands were sent monthly identification cards to be returned if they had diagnosed a new case of IBD in a pediatric patient. Follow-up questionnaires were sent to physicians reporting new cases of IBD. The pathology database contains reports from all cytologic and histologic diagnoses made in the Netherlands. Two independent raters searched the database for new IBD cases. Cases identified from the pathology database were labeled as "probable IBD" and "possible IBD." Cases were cross-checked across databases on the basis of gender, date of birth, date of biopsy, and place of residence. Age-specific incidence rates were calculated for the Dutch population for the year 2000.

RESULTS

Five hundred forty-six probable cases of IBD were identified; 217 cases were labeled as possible. The incidence rate was 5.2 new cases per 100000 children (<18 years) per year. An increase in incidence with age was observed. Only 24% of the cases were ascertained through the clinical registry.

CONCLUSION

The incidence of IBD cases in the Netherlands is comparable with that reported in other European countries. Epidemiological studies using case reporting by physicians may be underestimates of true incidence rates.

Epidemiological changes in diagnosed coeliac disease in a population of Spanish children

AIM

To investigate the incidence rate of diagnosed coeliac disease among the paediatric population in the province of Cáceres and the changes over the years.

METHODS

The incidence rate of diagnosed coeliac disease between the years 1981 and 1999, age at diagnosis and clinical presentation form were investigated. The study was carried out over two periods: A (1981 to 1990) and B (1991 to 1999).

RESULTS

The incidence rate for period A was 6.87/100,000 (CI 95%: 5.26-8.83) and for period B 16.04/100,000 (CI 95%: 12.99-19.59) (p < 0.0001). The relative risk of receiving a diagnosis of coeliac disease during the first four years of life was 2.31% (CI 95%:1.61-3.31) greater in period B than in period A. The mean age at diagnosis was 37.4 +/- 47.4 mo and 43.9 +/- 43.7 mo in A and B, respectively (p = 0.0058). The typical clinical pattern was the most frequent (83.6% in A and 58.3% in B). The mean age of introduction of gluten to the diet was 4.6 +/- 2.0 mo and 6.9 +/- 1.7 mo, for period A and B, respectively (p < 0.0001).

CONCLUSION

The incidence rate of coeliac disease has increased during the two periods studied. In recent years, the relative risk of receiving a diagnosis of coeliac disease during the first four years of life has increased. The atypical clinical presentation has also increased, although the typical clinical form is still the most frequent in younger children.

Dyspeptic symptoms in primary care. An observational study in general practice

BACKGROUND AND AIMS

Dyspepsia frequently causes patients to consult a general practitioner, but is generally investigated in referral centres. This study describes features of dyspepsia and its relationship with demographic, clinical and socio-economic factors in patients seen by general practitioners in Italy.

PATIENTS AND METHODS

In Italy, 10 000 general practitioners were asked to recruit up to 10 consecutive dyspeptic patients during a 1-month period. Painful and non-painful dyspeptic symptoms, retrosternal pain/burning and visible abdominal distension were graded 0-3 by a validated questionnaire. Demographics and clinical features were also recorded.

RESULTS

During the test period, 43 446 patients were included (55% were men; 50% were over 45 years old; 49% were smokers; 45% had experienced symptoms for > or = 1 month; 28% had a history of peptic ulcer). Dyspepsia accounted for 8.3% (range 3-11%) of the consultations of a subset of participating doctors. Epigastric pain and fullness were reported in 84% and 79% of patients, respectively. Dyspeptic symptoms were moderate-severe (graded > or = 2) in 69% of patients. Predominant epigastric pain and predominant discomfort were reported in 21% and 25% of the cases, respectively. Male gender, smoking, nocturnal awakening, overlapping reflux symptoms and a history of peptic ulcer were more frequent in patients with predominant pain, while female gender and overlapping abdominal distension were more common in patients with predominant discomfort. Age, educational level and working status were not related to any symptom pattern. Young patients presenting for the first time with uncomplicated dyspepsia accounted for 10% of the dyspepsia workload.

CONCLUSIONS

Dyspepsia accounts for a relevant workload for general practitioners. A considerable overlap exists among digestive symptoms. The proportion of patients that can be empirically treated according to current guidelines may be lower than expected.

Social position of adolescents with chronic digestive disorders

OBJECTIVE

To investigate the consequences of having a chronic digestive disorder on the social position of adolescents.

METHODS

Five diagnostic groups, including inflammatory bowel disease (IBD), chronic liver diseases, congenital digestive disorders, coeliac disease and food allergy (total n = 758, ages 12-25 years), were each compared with a population-based control group in a multicentre study using a cross-sectional design. Social position was assessed by a mailed questionnaire measuring 24 aspects, categorized as education, leisure activities, friendship, labour participation, financial situation, partnership and sexuality.

RESULTS

Eight aspects of social position were found to be affected negatively by one or more chronic digestive diseases: absence from school due to illness, going out, having a paid job, needing re-education in order to get a job, getting benefits as main income source, encountering bottlenecks in establishing financial commitments, having self-confidence in making a pass at someone, and restrictions in making love. Adolescents with chronic liver disease and IBD were found to experience more restrictions in social position. Adolescents with food allergy and congenital digestive disorders appear to experience some restrictions, but to a lesser degree, and adolescents with coeliac disease do not appear to have any problems regarding social position compared with controls.

CONCLUSION

The social position of adolescents is affected negatively by having a chronic digestive disease, in particular chronic liver disease and IBD. Negative consequences occur in education, leisure activities, labour participation, financial situation, partnership and sexuality.

Changing face of adult coeliac disease: experience of a single university hospital in South Yorkshire

OBJECTIVE

To determine the incidence and presenting features of adult coeliac disease in a single university hospital in South Yorkshire.

DESIGN

A retrospective case finding study. Data were obtained from pathology and immunology databases, clinical notes, dietetic records, and patient questionnaires.

SETTING

Royal Hallamshire Hospital in South Yorkshire, England.

PARTICIPANTS

All recorded cases of coeliac disease.

MAIN OUTCOME MEASURES

Crude annual incidence rates for coeliac disease was obtained. The numbers of coeliac antibody profiles requested per year from the Royal Hallamshire Hospital were ascertained. Age at diagnosis, sex, year of diagnosis, presenting symptoms, associated conditions, and delay in diagnosis was documented. In addition the specialty of the clinician who made the diagnosis was noted.

RESULTS

There were 264 cases in total (male n=86, ratio 1:2). Mean age at diagnosis was 44.9 years (range 1-82, median 44.5). A trend was observed from 1990 to 2000 inclusive, of an annual increase in the incidence of coeliac disease. There has been a coincidental increase in the measurement of associated antibodies. Although 28.4% of patients presented with gastrointestinal symptoms, 20.1% had iron deficiency anaemia. The ratio of typical to atypical symptoms was 1:2.5. (single sample test of proportions p<0.001). The diagnosis was made by a gastroenterologist in only 52.7% of cases. The median duration of symptoms before the diagnosis of coeliac disease was 4.9 years (range 0.25-16 years).

CONCLUSION

Coeliac disease is now presenting more commonly without gastrointestinal symptoms and often to specialties other than gastroenterology. Although more cases are diagnosed, this may be a reflection of increasing recognition rather than a true increase in incidence.

Does breast-feeding affect the risk for coeliac disease?

Coeliac disease, or permanent gluten sensitive enteropathy, has emerged as a widespread health problem. It is considered an immunological disease, possibly of autoimmune type, albeit strictly dependent on the presence in the diet of wheat gluten and similar proteins from rye and barley. There are reasons to believe that the aetiology of coeliac disease is multifactorial, i.e. that other environmental exposures than the mere presence in the diet of gluten affect the disease process. Our studies have shown that prolonged breast-feeding, or perhaps even more important, ongoing breast-feeding during the period when gluten-containing foods are introduced into the diet, reduce the risk for coeliac disease. The amount of gluten consumed is also of importance in as much as larger amounts of gluten-containing foods increase the risk for coeliac disease, while it still is uncertain if the age for introducing gluten into the diet of infants is important. Thus, a challenging possibility, that need to be further explored, is if the coeliac enteropathy can be postponed, or possibly even prevented for the entire life span, by favourable dietary habits early in life.

Inflated wings, tissue autolysis and early death in tissue inhibitor of metalloproteinases mutants of Drosophila

In vertebrates, tissue inhibitors of metalloproteinases (TIMPs) play key roles in extracellular matrix (ECM) homeostasis and growth control. Deletion of the recently cloned Timp gene of Drosophila results in a subviable phenotype. Adult flies display inflated wings similar to integrin mutants, suffer from a bloated gut and progressive dissolution of internal tissues, and die prematurely. Our results demonstrate that the Timp gene product controls selective aspects of ECM function in Drosophila, and suggest that it is involved in cell adhesion/cell signaling pathways. Hence, Drosophila Timp mutants may prove useful as a model system for a wide variety of pathological conditions related to ECM dysregulation.

Identification of coeliac disease in primary care

BACKGROUND

Coeliac disease is common yet often undiagnosed because symptoms may be trivial, non-specific, or non-gastrointestinal, or because of lack of clinician awareness. Serum IgA-class endomysial antibodies (EmA) have high specificity for coeliac disease and may facilitate case-finding by clinicians other than gastroenterologists. We assessed the appropriateness and diagnostic yield of of requests for EmA by primary care general practitioners in a defined geographic area of Northern Ireland.

METHODS

We identified patients who had EmA examination requests by their general practitioners during 1994-1996. Individual patient questionnaires were posted to the general practitioners concerned, seeking information on indications for testing, management after the result, and final diagnosis. We compared new patient diagnosis rates in two catchment areas, one served by a large district general hospital with, and the other by smaller hospitals without, a medical gastroenterology facility.

RESULTS

A total of 239 patients had coeliac profile testing by 69 of 177 general practitioners in the area. Data were available for 181 patients not previously known to have coeliac disease, of whom 20 (11%) had EmA. All EmA-positive patients were referred to hospital, where 19 underwent small-bowel biopsy, which confirmed coeliac disease in all 19. Only 7 (35%) of the 20 had diarrhoea, and there was no significant difference in EmA prevalence among patients tested with and without diarrhoea. Although the mean number of new patients (per 100,000 population annually) diagnosed by biopsy was 11 at the large hospital compared with 5 elsewhere, the numbers identified by EmA in general practice for the 2 catchment areas were similar (2 and 3, respectively).

CONCLUSION

General practitioners have an important role in the identification of patients with coeliac disease, particularly where there is no local medical gastroenterology facility, and this is facilitated by EmA testing.